REVUE DE LA LITTRATURE / LITERATURE REVIEW

Mdecine dentaire factuelle / Evidence-Based Dentistry

BENEFITS AND LIMITATIONS OF EVIDENCE-BASED

DENTISTRY IN THE INDIAN CONTEXT

Varun Suri* | Vanita Suri** |

Abstract
The American Dental Association defines the evidence-based
dentistry (EBD) as an approach to oral health care that requires
the integration of systematic assessments of clinically relevant
scientific evidence, relating to the patients oral and medical
condition and history, with the dentists clinical expertise and
the patients treatment needs and preferences [1].
Nowadays, evidence-based care is regarded as the gold stan-
dard in health care delivery. Published reports of research pro-
jects constitute the basis of EBD. They are analyzed systemati-
cally in meta-analysis.
This paper investigates the concept of evidence-based dentistry,
its benefits and its limitations.
Keywords: Evidence-based dentistry clinical practice
decision making.
Rsum
LAssociation des Dentistes des Etats Unis dfinit la dentiste-
rie fonde sur des donnes probantes comme une approche
aux soins de sant bucco-dentaire qui ncessite lintgration
des valuations systmatiques des preuves scientifiques cli-
niquement pertinentes, relatives la situation et lhistoire
orale et mdicale du patient, lexpertise clinique du dentiste
et aux besoins et prfrences thrapeutique du patient [1].
De nos jours, les soins fonds sur des preuves sont consid-
rs comme ltalon-or dans la prestation des soins de sant.
Les rapports publis des projets de recherche constituent
la base de cette dentisterie. Rapports et rsultats dtudes
sont analyss systmatiquement par des mta-analyses.
Cet article tudie le concept de la dentisterie fonde sur les
preuves, ses avantages et ses limites.
Mots-cls: qualit des soins dcision thrapeutique.

* Post-graduate student ** Professor,

Public Health Dentistry, Department of Obstetrics and Gynaecology,
Swami Devi Hospital and Dental College, Post Graduate Institute of Medical Education
Panchkula, Haryana, India and Research, Chandigar, India
drvarunsuri@gmail.com

Introduction
Evidence-based medicine (EBM)
has been defined as the conscien-
tious, explicit, and judicious use of cur-
rent best evidence in making decision
about the care of individual patients
[2]. It is a thoughtful integration of the
best available evidence, coupled with
clinical expertise [3]. It enables one to
address healthcare questions with an
evaluative and qualitative approach.
It is about applying the best avai-
lable research evidence in provision
of health, behavior and education ser-
vices to enhance outcomes [4].
In the 21st century, the practice of
dentistry is becoming more challen-
ging because of the information explo-
sion regarding dental materials and
equipment and the increasing need for
continuous professional development.
Evidence-based dentistry (EBD)
has been gaining even more impor-
tance in the past few years in order
to reduce the gap between clinical
research and actual dental practice.
The clinical research is the basis for
EBD; it allows us to make decisions
about the causes of a disease and
its treatments, while allowing for the
natural differences between people.
Dental education and dental care
delivery systems are greatly improved
in India due to the increased dental
health workforce and development in
the field of dental research. However
dental graduation training program
in India is mainly targeted towards
preventive and curative dental proce-
dures. There is a lack of emphasis on
the application of EBD in practice.
On the other hand, the term EBD is
widely used, but not widely unders-
tood among post-graduates due to the
lack of in-depth training to distinguish
good science from poor science. Most
of the post-graduate dental students
clinical questions and problems are
solved by a combination of instructors
intuition, training and clinical expe-
rience, which may or may not be based
on scientific evidence.
Mdecine dentaire factuelle / Evidence-Based Dentistry
6 Meta-
analyses
and systematic
reviews
Randomized
5 controlled
clinical trials
4 Cohort studies
3 Case control studies
2 Case series
1 Animal models, in vitro studies,
biological plausibility,
expert opinion
Fig. 1: Levels of evidence in evidence-based care.
The main goals of EBD are
[3, 5]:
1- Getting the best evidence /
research;
2- Transfer of that evidence in prac-
tical use.
Graduates from dental schools are
up to date with the best practice in
dentistry at the time they graduate.
Some of this knowledge gradually
becomes out of date as new infor-
mation and technology appear. It is
important, especially with regards to
patient safety, for dentists to be able to
keep up with developments in diagno-
sis, prevention and treatment of oral
diseases, and newly discovered causes
of diseases.
Benefits of evidence-based dentistry
It is well known that implementa-
tion of research evidence into clini-
cal practice is an important compo-
nent of any health care practice [3, 4].
However, research findings are inade-
quately disseminated and transmit-
ted to practitioners who tend to resist
accepting new information or applying
new techniques. Since the inception
of EBM in the early 1990s, the rapid
growth of internet has made it easier
for practitioners to gain access to most
current evidence [6]. It is clear that
dentists, members of the dental team,
and patients are the primary targets
for continued evolution of EBD. The
importance of EBD can be applied to
the following:
119
Evidence-base
High level evidence
from systematic experiments
Low level evidence
EBD and dental education
Contemporary dental education
has evolved over many years. The
University of Maryland School of
Dentistry is the dental school of the
University System of Maryland. It was
founded as an independent institu-
tion, the Baltimore College of Dental
Surgery, in 1840. It is known as the first
dental college in the world [7, 8].
Gradually all proprietary dental
schools were closed and were replaced
by university based program in order
to maintain the teaching standards
and educational quality. As the evi-
dence based medicine became popu-
lar, incorporating the EBD was needed.
Wide variations in practice patterns
and outdated approaches to the den-
tal treatment were applied. Currently,
significant time in curriculum is
devoted to teaching the principles of
EBD.
Benefits for the practicing dentists
The application of EBD in clini-
cal practice implies many potential
benefits to the practicing dentists.
Treatment plans are customized based
on clinical judgment and experience as
well as scientific evidence. Also, there
is reduced overhead and improved
production by saving time and money
using techniques and materials that
are effective and efficient.
Benefits in research
EBD is a method for gathering,
selecting and applying the best evi-
dence in clinical practice.
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IAJD Vol. 7 Issue 3
It encourages the students and
clinicians to carry out research in
the areas where there is need of evi-
dence, such as multicentric rando-
mized studies, systematic reviews and
meta-analysis.
Levels of EBD
The idea of dental practice based
upon sound, evidentially-based
concepts has been embraced by the
American Dental Association and the
Commission on Dental Accreditation
(CODA) in their new mandates for den-
tal education [9].
It is appropriate to represent the
levels of evidence as a pyramid, with
the reliability of evidence highest at
the apex (Fig. 1). The lowest levels
are expert opinion, biological plausi-
bility, laboratory bench research, ani-
mal studies and then case-series. The
adjective low-level does not refer to
the intrinsic (or inherent) quality or
value of the evidence, but rather as to
how such evidence is valued when it
is used as a basis for making clinical
decisions for humans.
High-level evidence consists of
controlled systematic experiments in
humans: primarily case-control stu-
dies, cohort studies and randomized
controlled trials. Instead of using
deductive reasoning to connect a
cause to its effect in humans, observa-
tions are made on a sample of subjects
and are generalized using inductive
inference.
Case-control studies and cohort
studies are commonly used to elu-
cidate causes of disease, and often
form the basis for public health recom-
mendations. Case-control studies can
show associations between variables
but cannot however prove causa-
lity. Randomized controlled trials are
at the top of the evidence pyramid,
since these trials eliminate many of
the inherent and often uncontrollable
biases present in case- control studies
and cohort studies by randomly assi-
gning individuals to different treat-
ment groups.
Systematic reviews and meta-ana-
lyses synthesize the results of several
randomized controlled trials; they offer
the highest level of evidence.
Limitations of EBD
A range of limitations of evidence-
based healthcare have been identified.
Briefly, these can be listed as follows
[10]:
- Shortage of coherent and consistent
scientific evidence.
- Difficulties in applying any evidence
to the care of individual patients.
- Barriers to the practice of high-qua-
lity medicine.
- The need to develop new skills in
identifying answerable questions,
searching for and critical appraisal
of the evidence.
- Limited time to master and apply
these new skills.
- Limited evidence of positive
patient outcomes following EB
interventions. decisions.
- Limited access to resources to pro-
vide timely access to evidence in
clinical settings.
The above limitations do not relate
to the approach but rather to the
implementation of an EB approach to
healthcare. To implement EB health-
care, support for practitioners, educa-
tors and students is needed to develop
skills within integrated settings, and to
evaluate available evidence, including
information provided to assist in the
application of this evidence to indivi-
dual patients [10].
Managing uncertainty
Whilst it is clear that the evidence
base in oral healthcare is not as fully
developed as in medicine, the limi-
tation of evidence raises other key
concepts that students and practitio-
ners need to manage, especially in a
country like India. Specifically, a lack of
evidence is not evidence of any effect
whatsoever, and students and practi-
tioners also need to learn to manage
uncertainty [11].
As part of managing uncertainty
there is a need to support students to
understand and work with the concepts
of efficacy and effectiveness and toge-
ther with Evidence-Based Oral Health
Care (EBOHC) and risk assessment,
these may assist in informing clinical
decisions. Otherwise if the definition
of appropriate evidence is too narrow,
there is a risk of allowing uncertainty to
cause paralysis in healthcare or unrea-
sonably abandon EBOHC principles
rather than use them to acknowledge
and manage uncertainty constructively
[12].
Misperceptions about EBD
Other criticisms of EB healthcare
are really misperceptions which arise
from ignoring key aspects of the steps
in EB processes [10]. EB healthcare
does not ignore or devalue clinical
experience or patient or community
values, but rather requires integration
of evidence with clinical experience
and expertise, and patients or com-
munitys values to reach appropriate
Lack of universal applicability
There is also the issue of the appli-
cation of guidelines developed for one
population being applied to another
population which may have different
disease prevalence [13]. Both of these
issues can be addressed through
the development of effective critical
appraisal skills and by the use of crite-
ria to evaluate clinical guidelines deve-
lopment [14], with subsequent redeve-
lopment of appropriate guidelines for
the Indian context.
Socio-cultural elements
Socio-cultural factors that influence
the application of evidence in decision-
making include patients demands for
care, and their beliefs and perceptions
of what is appropriate care. Requests
for inappropriate tests/treatments can
lead to poor adherence to clinical gui-
delines [15]. The influence of patients
on their own care has been demonstra-
ted in oral healthcare, where treatment
philosophies and care provided have
resulted in patients preferences over-
riding evidence [16].
Therefore, we need to support
students and practitioners in develo-
ping competence in communication

skills related to managing conflict,
as well as educating patients on the
management of their problems. This
aspect of patient care may be further
assisted by the development of deci-
sion aids, which have been reported to
be effective in supporting patients in
making informed decisions [17].
Concerns about professional autonomy
The professional autonomy of cli-
nicians might be at risk due to misuse
of EBD in practice. Supported by their
own interpretation of the right way to
treat a particular condition, gathered
from any evidence-based information
according to their whims and fancies,
Managed Care Organizations (MCOs)
and health plans (private as well as
governmental) might well seize the
opportunity to limit services and pro-
cedures provided by such plans to save
money. Such acts will leave no place
for the discretionary ability of a dental
clinician to apply the art and science of
dentistry in practice.
While EBD is a very promising way
towards better health care, there will
always remain the fear that cookbook
types of dental protocols might replace
the appropriate integration of the best
available evidence with sound clinical
judgment for treating patients [18].
Mere guidelines cannot, and should
not, be used to replace face-to-face
contact with dental professionals,
which allow patients the opportunity
to raise questions and concerns regar-
ding their treatment.
Legal hassles
Once the Indian dental scenario
gets sufficiently mature, the interpre-
tation of any EBD practice will present
new challenges to the judicial system
as courts seek to codify and simplify
legal issues in the entire health care
field. After-the-fact culpability charges
shall result in very complex dental
liability issues. Expert witnesses will
need to be better educated and well-
versed in the current evidence-based
literature and resulting systematic
reviews in a particular area of dentistry.
Mdecine dentaire factuelle / Evidence-Based Dentistry
Doubts on practicability
Many studies in dentistry as well
as medicine unavoidably lack inclu-
sion criteria, hence their practical
and immediate application in patient
care is limited to a narrow patient
base. Hence even the best designed
and implemented trials (randomized,
controlled and otherwise) need to be
assessed in their proper context when
applying them to clinical problems.
Everything cannot be proved
In order to achieve a maximal
control, the control group should
match or presents a very small diffe-
rence compared to the experimental
group. However, this can be difficult to
find or even sometimes impossible to
find. This makes proving any hypothe-
sis merely difficult. Very rare condi-
tions preclude the application of EBM
principles just because a sufficient
number of cases cannot be found to be
considered as substantial evidence.
Organizational issues
Organizational considerations
have to be taken into account because
of the functioning of research in the
framework of institution and finan-
cing of research. Because of a lack of
funding or the lack of somebody who
champions the project in funding com-
mittees, not all questions that deserve
answering find a place on the agenda
of organizations.
Inapplicability to specific products
Finding evidence for one specific
product is not always as easy as fin-
ding evidence in a general way. This
is because a product's turn-over gene-
rally is faster than the process of set-
ting up a clinical study, performing it,
interpreting the results, writing of the
report and having it published. In a
study by Dr. Bottenberg, two out of the
three composites tested were no lon-
ger available by the time of publication
of the study [19].
Voluminous / jargon- full reports
Studies have shown that Indian
postgraduates lack adequate skills to
121
appraise scientific journals, mainly
due to limited knowledge of the termi-
nologies used in evidence-based den-
tistry [20]. Dental curriculum should
be modified to overcome this barrier.
It is clear that evidence-based den-
tistry must strive to be a practical and
beneficial aid to the average dentist,
and that the generation of copious and
erudite documents must therefore be
avoided.
Inherent limitations in systematic
reviews
There are some inherent problems
and limitations of some systematic
reviews, meta-analyses and rando-
mized clinical trials that are not as
well-recognized in dentistry as they are
in medicine.
There are several limitations of
systematic reviews. First, Flores-Mir
et al. [21] found that the search and
selection methods of current syste-
matic reviews in orthodontics, for
example, (i.e., from 2000 to 2004) are
limited in that key methodological
components are frequently absent or
not appropriately described. For the
16 orthodontic systematic reviews for
this time period, many failed to search
more than Medline (56%), 37% failed
to document the database names and
search dates, 62% failed to document
the search strategy, 75% did not use
several experts to select studies, and
81% did not include all languages [21].
Next, by asking general and broad
questions, systematic reviews often
produce results and conclusions with
questionable validity. Poorly focused
questions in systematic reviews lead to
unclear decisions about what research
to include and how to summarize it.
Part of the problem is that some sys-
tematic reviews, or the research stu-
dies they are based upon, have not
accounted for confounders that may
preclude appropriate interpretations.
Poor systematic reviews will invariably
lead to inaccurate conclusions that
will then negatively impact upon clini-
cal practice. Further, when systematic
reviews are based on randomized cli-
nical trials that are also poorly defined
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IAJD Vol. 7 Issue 3
and directed, the error and impact on
clinical practice multiplies.
Limitations of randomized controlled
trials
As in other types of prospective
studies, randomized clinical trials are
susceptible to biases of compliance
and long-term attrition. Not all sub-
jects comply with the regimen to which
they are assigned, and for studies that
require long follow-up periods, there is
a natural tendency for a high dropout
rate.
Moreover, because it takes such
a long time to complete prospective
trials, by the time the studies are com-
plete, the appliance and /or procedure
that were investigated may not even
be considered and/or utilized in prac-
tice. Although the goal of conducting
high quality randomized clinical trials
is noble, the reality is that many clini-
cal research questions are amenable
to well-designed and cost-effective,
observational (cross-sectional) studies
such as cohort or case-control studies.
Also, there are ethical concerns
involving randomized clinical trials
studies using human subjects. In gene-
ral, there is the moral foundation that
health care providers should not disad-
vantage subjects on account of their
research participation. There must
be a genuine uncertainty on behalf of
the expert community concerning the
merits of each trial arm (clinical equi-
poise); otherwise, obtaining proper
informed consent becomes an issue.
More importantly, when there is
no clinical equipoise, there may be
an additional ethical concern with
randomized clinical trials due to ran-
domization into experimental and
control groups whereby subjects in the
control group may be disadvantaged
significantly by not receiving the more
appropriate treatment in the long term
(e.g., extraction versus non-extraction,
orthodontics versus surgery, and long
versus short treatments).
In addition, a researcher cannot
ethically create a disease or disorder in
one group of subjects, study the effects
of the disease (and several treatment
modalities), and compare it with a
sample that does not have the disease.
The issue does not really appear
to be whether randomized clini-
cal trials are capable of addressing
various controversies in dentistry and
orthodontics: They are. The issue is
whether we can justify the large costs
and time associated with such trials
when simple, cost-effective retros-
pective or observational cohort stu-
dies may arguably reveal the same
results. In a specialty for which only
limited research funding is available,
we must seek not only evidence but
also frugality. Retrospective studies
are quick, cost-effective, and ethically
unambiguous.
Limitations of meta-analysis
For a meta-analysis, i.e. a mathe-
matical and quantitative (statistical)
synthesis of the results of two or more
primary studies that address the same
hypothesis or topic in the same way,
it is important that the methods used
for the review are reliable, valid, and
well-characterized. Meta-analyses are
by all accounts superior to qualitati-
vely based evaluations of numerous
studies.
The preliminary aspects of the
meta-analysis (prior to applying the
actual statistical test), however, are
subjective (even though there are
certain rules and guidelines); there is
the subjective judgment in deciding
which studies to include. A number of
problems are inherent to meta-ana-
lyses: regressions are often nonlinear,
effects are often multivariate rather
than univariate, coverage can be res-
tricted, bad studies may be included,
the data summarized may not be
homogeneous, grouping different cau-
sal factors may lead to meaningless
estimates of effects and the theory-
directed approach may obscure discre-
pancies [22].
Altman [23] believed that the meta-
analyses (and systematic reviews)
of prognostic studies are difficult.
Prognostic studies include clinical stu-
dies of variables predictive of future
events as well as epidemiological stu-
dies of etiological risk factors. Authors
often have concluded that a meaning-
ful meta-analysis for prognostic stu-
dies is not possible due to a set of stu-
dies being too diverse and/or too weak.
According to Altman [23], the poor
quality of the published literature is a
strong argument in favor of systematic
reviews and an argument against for-
mal meta-analysis.
Meta-analyses are sometimes used
incorrectly to recover something from
poorly designed studies; studies with
insufficient statistical power and stu-
dies resulting in apparent contradic-
tions. No statistical test can overcome
and rectify the methodological short-
comings of poorly designed primary
studies.
In summary, there is no doubt that
the meta-analysis has its place in the
evidence-based dentistry paradigm
and is an integral part of a systematic
review; however, the validity of its fin-
dings is greatly dependent on the qua-
lity of the individual studies incorpora-
ted into the analysis.
Keeping all the above limitations
in mind, EBD needs to be used wisely,
justly, ethically and expertly by all den-
tal professionals. It is after all a tool
and any tool can end up getting used
poorly with adverse results. EBD must
be used to significantly enhance the
critical role that dental clinicians play
in patient care.
Conclusion
Evidence-based care is a global
movement in all the health science
disciplines. It represents a philoso-
phical shift in the approach to practice
- a shift that emphasizes evidence over
opinion and, at the same time, judg-
ment over blind adherence to rules [1].
EBD requires the integration of the
best evidence with clinical expertise
and patient preferences and, therefore,
it informs, but never replaces, clinical
judgment [2].
A common misconception is that
evidence-based practice is not feasible
or is ineffective in the absence of ran-
domized controlled trials. Although
 123

Mdecine dentaire factuelle / Evidence-Based Dentistry

randomized trials are the gold stan-
dard for judging therapeutic interven-
tions, they may not be available or they
may not be the appropriate research
design to answer other types of clini-
cal questions. Evidence-based practice
is a practical approach to clinical pro-
blems. It involves tracking down the
best available evidence, assessing its
validity and using rules of evidence
to grade the evidence according to its
strength [24].
The fact that scientific research
evidence has built the knowledge
base and has always provided the
foundation for sound practice of the
profession of dentistry is not in dis-
pute. However, the context for change,
making the practice of EBD pos-
sible, is the electronic revolution. The
research evidence can now be readily
accessed at the user level by den-
tists or patients. Because the quality
of research reports and, therefore, the
accuracy of the conclusions drawn,
vary tremendously, tools are needed to
help dentists to properly interpret and
apply the evidence [25].
Research works in various branches
of dentistry is on the rise in India,
mainly by the postgraduate dental
students and by the faculties of the
various dental colleges; thus there
is a need to update their clinical
knowledge to improve their research
outcomes. Evidence based dentistry is
the solution to provide such updates
in order to improve the quality of
research in India. There should be an
adequate program developed in the
form research workshops and semi-
nars on evidence-based dentistry to
overcome the barriers perceived by the
postgraduates in practice of evidence-
based dentistry, thereby integrating
this concept into routine clinical prac-
tice in order to improve the quality of
dental care provided to the patient.

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